| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
537 |
312 |
$218K |
| D1110 |
Prophylaxis - adult |
3,202 |
3,198 |
$104K |
| D0210 |
Intraoral - complete series of radiographic images |
2,373 |
2,344 |
$41K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
509 |
358 |
$39K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,946 |
1,942 |
$39K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,846 |
2,817 |
$37K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
483 |
335 |
$31K |
| D0220 |
Intraoral - periapical first radiographic image |
3,430 |
3,405 |
$28K |
| D2954 |
|
275 |
198 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
1,155 |
1,155 |
$22K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
260 |
146 |
$19K |
| D0274 |
Bitewings - four radiographic images |
824 |
824 |
$16K |
| D4341 |
|
87 |
83 |
$9K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
38 |
30 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
324 |
323 |
$2K |
| D9310 |
|
46 |
46 |
$2K |
| D2330 |
|
30 |
27 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
104 |
104 |
$1K |
| D9940 |
|
12 |
12 |
$936.00 |
| D1120 |
Prophylaxis - child |
30 |
30 |
$900.43 |
| D0272 |
Bitewings - two radiographic images |
68 |
68 |
$845.08 |
| D9110 |
|
12 |
12 |
$157.84 |